Bile duct injury during laparoscopic and conventional cholecystectomy

It has been suggested that the risk of injury to the bile duct is higher after laparoscopic cholecystectomy than after conventional cholecystectomy. The results of previous studies on laparoscopic cholecystectomy showed no difference but they were limited (positive) selections from highly specialized centers. Thus, a questionnaire was sent to all surgical departments in The Netherlands to analyze the number of repair procedures for bile duct injury, the techniques and complications of this treatment and the number of cholecystectomies performed during 1991 to determine the "actual" risk of bile duct injury. The response was 88.4 percent (122 of 138 centers). A total of 11,712 cholecystectomies were performed, of which 2,932 were laparoscopic and 8,780 were conventional. Thirty-two bile duct injuries resulted from laparoscopic cholecystectomy (1.09 percent) and 45 resulted from conventional cholecystectomy (0.51 percent) (p < 0.001). Thirty-six injuries (46.7 percent) were detected during the procedure or within 24 hours and 41 (53.2 percent) after a mean period of ten days. The bile duct lesion consisted of transection in 35 patients (45.5 percent), a stenosis or clips in 17 patients (22.1 percent) and a lesion with bile leakage in 25 patients (32.5 percent). The repair procedure included primary closure or end to end anastomosis in 33 patients (42.8 percent) and hepatojejunostomy in 31 patients (40.2 percent). Hepatojejunostomy was performed upon 17 percent of the injuries detected early and in 61 percent of the injuries detected after a delay. Complications were found in 31.1 percent and the mortality rate was 7.8 percent. In summary, the risk of bile duct injury after laparoscopic cholecystectomy was significantly (p < 0.001) higher than after conventional cholecystectomy, which was probably related to the relative inexperience (all units from one country). The risk of bile duct injury after conventional cholecystectomy was slightly higher than that found in literature, which probably reflects the fact that we studied the number of "repair procedures" instead of registration of complications (injury). Repair procedures for lesion detected after a delay are more complicated (hepatojejunostomy) than for the injury detected early.